The results of the District Level Household and Facility Survey-4 for the year 2012-13, commonly known as DLHS-4, are out and it shows that among the 18 states and 3 UTs, the percentage of moderate wasting for children below 5 years is highest in Maharashtra (i.e. 34.1 percent). Similarly, in the case of severe wasting and moderate underweight, the situation is worst in Maharashtra as compared to the rest (as shown in the chart below).
The above outcomes may be shocking for those who were rather pleased with the state's reported decent performance in reducing stunting (too short for age) among children under 2 years, and expected similar trends for the other two indicators of nutrition levels, namely wasting (too thin for height) and underweight (too thin for age).
Earlier, the provisional results of the Comprehensive Nutrition Survey (CNS) in Maharashtra during 2012, conducted jointly by the state's Department of Women and Child Development, International Institute for Population Sciences (IIPS) and UNICEF, found that the percentage of children below 2 years affected by stunting came down drastically to 22.8 percent in 2012 (under CNS) from 39.0 percent in 2005-06 (under the National Family Health Survey or NFHS-3).
Since the publication of the CNS results, many international reports, authored by renowned economists and health experts, had praised the state for reducing malnutrition among children, although there were some critical reports, too, by the media on high malnutrition levels prevailing particularly among tribal children in parts of Melghat in Amravati, Jawahar and Mokhada in Thane and urban slums of Mankhurd and Shivajinagar in Mumbai.
Since the DLHS-3 done in 2007-08 (and published in 2010) did not provide information on malnutrition, DLHS-4 can be straightway compared with NFHS-3 for the states whose latest nutritional data is available now.
On doing so, we find that moderate stunting among children below 5 years in Maharashtra has reduced from 46.2 percent in 2005-06 (NFHS-3) to 30 percent in 2012-13 (DLHS-4) while severe stunting came down from 19.1 percent to 14.7 percent during the same duration.
However, prevalence of moderate wasting nearly doubled and that of severe wasting quadrupled in the 7-year span for children below 5 years.
Although prevalence of moderate underweight children under 5 years in the state remained almost the same between NFHS-3 and DLHS-4, those severely underweight in the same category increased slightly over the same time period.
Performance of various states under DLHS-4
In terms of prevalence of 'moderate wasting,' among 18 states and 3 UTs, Maharashtra (34.1 percent) performs the worst and Nagaland (10.8 percent) performs the best. Except for Andhra Pradesh, Arunachal Pradesh, Kerala, Nagaland and Sikkim, the prevalence of 'moderate wasting' is higher in rural areas as compared to urban areas. The rural-urban divide is maximum in Andaman and Nicobar Islands.
The percentage of 'severe wasting' is highest in Maharashtra (20.0 percent) and lowest in Nagaland (5.2 percent). The prevalence of 'severe wasting' is higher in rural areas as compared to urban areas, except for Himachal Pradesh, Kerala, Nagaland and Sikkim. The rural-urban divide is maximum in Puducherry.
In terms of prevalence of 'moderate stunting', Meghalaya (41.7 percent) performs the worst and Goa (18.7 percent) performs the best. Except for Goa, Himachal Pradesh, Karnataka, Maharashtra, Puducherry and Telangana, the prevalence of 'moderate stunting' is higher in rural areas as compared to urban areas. The rural-urban divide is maximum in Tripura.
The percentage of 'severe stunting' is highest in Meghalaya (23.1 percent) and lowest in Goa (8.4 percent). The prevalence of 'severe stunting' is higher in rural areas as compared to urban areas, except for Andaman and Nicobar Islands, Arunachal Pradesh, Goa, Haryana, Karnataka, Punjab, Sikkim and Telengana. The rural-urban divide is maximum in Meghalaya.
In terms of prevalence of 'moderate underweight', Maharashtra (38.7 percent) performs the worst and Kerala (20.9 percent) performs the best. Except for Karnataka, the prevalence of 'moderate underweight' is higher in rural areas as compared to urban areas. The rural-urban divide is maximum in Andaman and Nicobar Islands.
The percentage of 'severe underweight' is highest in West Bengal (15.4 percent) and lowest in Sikkim (5.4 percent). The prevalence of 'severe underweight' is higher in rural areas as compared to urban areas, except for Goa. The rural-urban divide is maximum in Andaman and Nicobar Islands.
The lessons from Maharashtra
Although nothing definite can be said about reduction of malnutrition among children under the age of 5 years between NFHS-3 and DLHS-4, there are some important lessons that can be learnt from Maharashtra.
A commentary published in the Economic and Political Weekly titled Progress in Reducing Child Under-Nutrition: Evidence from Maharashtra by Sunny Jose and KS Hari (2015) informs that nutritional interventions through the Rajmata Jijau Mother-Child Health and Nutrition Mission, which began in 2005, played a crucial role in reducing the prevalence of stunting among children below 2 years in Maharashtra.
However, the decline in malnutrition levels was confined largely to children belonging to two or three age groups and while the interventions helped reduce stunting significantly, the impact was not as much on wasting and underweight children.
Jose and Hari have observed that in the 6-year span between NFHS-3 and CNS, stunting among children below 2 years belonging to the Scheduled Tribe (ST) households declined by 25.3 percentage points: from 52.9 percent in 2005-06 to 27.6 percent in 2012.
However, stunting among children below 2 years from Scheduled Caste (SC) and Other Backward Caste (OBC) households declined by much less than among ST children. A similar trend could be observed in the case of underweight children.
In the case of wasting, the decline was highest among children from SC households.
Girls have performed better than boys (in the below 2 years group) in terms of declining stunting, wasting and underweight between 2005-06 and 2012.
Jose and Hari inform us that the nutrition and health mission of Maharashtra launched a dedicated programme to bring down child undernutrition through a menu of interconnected measures, ranging from monitoring the nutritional status of pregnant women to ICYF practices and vaccination, among others.
In a note given in the Global Nutrition Report 2014 of the International Food Policy Research Institute (IFPRI), Professor Lawrence Haddad from IDS Sussex has explained the following key factors that helped in reducing stunting among children under the age of 2 years in Maharashtra:
Economic growth and poverty reduction helped in reducing malnutrition in the state. Maharashtra has a modest track record in transparency, anti-corruption efforts, and service delivery.
Spending on nutrition doubled from a low level, and vacancies among frontline workers in the Integrated Child Development Services (ICDS) scheme dropped dramatically.
The determinants that improved the most between the NFHS-3 and CNS surveys were the age of mother at first birth, maternal underweight, maternal literacy, coverage of antenatal visits, delivery in the presence of birth attendants, child feeding practices, and access to ICDS.
Underlying determinants were reasonably supportive: women’s decision-making status inside and outside the home was high, the Public Distribution System (PDS), which distributes subsidized food to poor people, suffered from slightly less leakage than the all-India average, and female education rates were high and rising.
The state’s Nutrition Mission was seen as a signal of high-level political commitment to nutrition improvements and helped coordinate different sectors at village and policy levels.
Caveat: Data comparability and methodology
One thing that readers must note about the DLHS-4 findings is that the data provided by it on stunting, wasting and underweight does not take into account the data from those (big) states where malnutrition levels have traditionally been higher (such as Bihar, Madhya Pradesh etc), as shown by the last three National Family Health Surveys (NFHS).
Thus, the DLHS-4 data is based on a much smaller survey (in terms of sample size) as compared to DLHS-3. The former has covered the better performing states but left out 9 such states where most malnourished children of India are concentrated. However, as pointed above, DLHS-3 did not provide information on the 3 measures of nutrition.
Despite the above fact, since the state-wise malnutrition figures based on the Rapid Survey on Children (RSOC) conducted by the Ministry of Women and Child Development in partnership with UNICEF India is not yet available in the public domain, the publication of the DLHS-4 data providing updated nutritional trends in a few select states is definitely a welcome step.
Of course, as many media reports have suggested, the publication of NFHS-4 would have done justice to the absence of comprehensive and comparable data since 2005-06.
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